Complex Ventral and Incisional Hernia Repair: Robotic versus Open TAR technique

Review

Hell J Surg. 2024 Oct-Dec;94(4):213–219
doi: 10.59869/24049

Fotis Archontovasilis1-3, Evgenia Mela3, Dimitrios Liatsos3, Tania Triantafyllou1,3

16th Surgical Department, Metropolitan General Hospital, Athens, Greece
2Center of Excellence (SRC certified) in Hernia Surgery, Metropolitan General Hospital, Athens, Greece
31st Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece

Correspondence:  Fotis Archontovasilis, Pythagora 7 St., Faneromeni, 15562, Cholargos, Attica, Greece, Tel.: +302106502850, +30 6974 442532, e-mail: arfotis@gmail.com

ABSTRACT

Ventral hernias, both primary and incisional, constitute a significant and complex clinical entity, despite advancements in repair techniques. Complex ventral hernias, including incisional hernias (IH), pose a greater surgical challenge due to larger defect dimensions, loss of domain, altered tissue integrity and higher risk of recurrence, thereby requiring the application of advanced repair techniques. In the contemporary era of surgery, transversus abdominis release (TAR) is being established as a preferred approach for complex ventral hernia repair, with robotic-assisted TAR (r-TAR) gaining prominence due to its minimally invasive advantages. This review analysed the historical evolution of ventral hernia repair and critically summarised current evidence comparing open TAR (o-TAR) and r-TAR in terms of intraoperative details and postoperative outcomes. Considering the intricate nature of complex ventral hernias, r-TAR has emerged as a promising alternative to o-TAR, indicating potential benefits in complications and length of hospital stay.

Key Words: Complex ventral hernia, incisional hernia, posterior component separation, transversus abdominis release, robotic hernia repair

Submission: 07.04.2025, Acceptance: 02.07.2025

INTRODUCTION

Incisional hernia (IH) is defined as any palpable defect of the abdominal wall, with or without protrusion, on the site of a previous surgical incision, which can be detected with either clinical or imaging methods [1]. Despite contemporary abdominal wall closure techniques, the incidence of IH remains notable. It ranges between 2-20%, even with the increasing implementation of minimally invasive techniques, including laparoscopy and robotic surgery, with some studies reporting incidence rates as high as 30% and 60% after two- and five-year follow-up periods, respectively. This disparity is resulting from several factors, involving the type of surgical approach and closure, potential defects during index surgery, wound infection and other comorbidities [1,2]. Despite advancements in complex hernia repair, IH is associated with longer operative time and hospital stay, increased risk of complications and reoperation rates [3-6]. A standardsed definition for complex IH has not been established. However, several factors are used in the classification and treatment planning of IH. These include hernia width (>10cm), shape of the defect, surgical wound classification, increased intra-abdominal pressure, fistula presence, loss of domain, previous recurrence and patient characteristics, mainly body mass index (BMI) and cirrhosis [1,3,5].

Multiple techniques have been implemented for complex IH repair. Among them is anterior component separation (ACS)first described by Ramirez et al,which utilises skin flaps to facilitate fascial closure. [7]. However, the transversus abdominis release (TAR) procedure has altered the natural history and treatment of complex IH. As described by Novitsky et al. in 2012 [8], TAR creates a well-vascularised preperitoneal level above the transversalis fascia for posterior mesh placement, avoiding the need for large skin flaps  [8]. It is, thus, perceived as a modification to the traditional Rives-Stoppa technique, and an alternative to the classic approach ofACS technique which necessitates  large skin flaps and may result in greater morbidity [7-9].

TAR is considered one of the preferred methods for addressinglargeIH , with defects exceeding 8-10 cm or even approaching 18-20 cm, exhibiting the benefits of reduced surgical site infection (SSI) and recurrence rates [10]. Additional advantages include the preservation of neuromuscular bundles , and therefore avoidance of ischaemia of the rectus abdominis muscles,the medialisation of the anterior fascia andthe recreation of the linea alba in large hernia defects , the substantial mesh overlap beyond the hernia defect and the relatively tension-free nature of the repair [5,8]. In addition to this, it represents a more functional restoration of the abdominal wall mechanics . [11] Mesh placement is extraperitoneal, reducing the complications of adhesions and fistulas, and obviating the need for traumatic fixation [12]. In this context, the advent of minimally invasive techniques has revolutionised IH repair by introducing the laparoscopic TAR and r-TAR, with the latter emerging as the method of choice, as it can overcome the established limitations of laparoscopic surgery [12].

The aim of this review is to summarise the historical background of ventral and IH repair, as well as evaluate the current evidence on the implementation of r-TAR for ventral and IHrepair and to compare it to the open approach, with respect to intraoperative details and postoperative outcomes.

HISTORICAL BACKGROUND

Ventral hernia repair has been a source of concern since antiquity, with the first description of anterior abdominal wall anatomy dating back more than 6,000 years, when Egyptians also described the first ventral hernia repair using heat [13].

In the contemporary era of medicine, the introduction of Rives-Stoppa repair technique by Jean Rives and René Stoppa dates back to1978 and 1989, respectively, who proposed the sublay, above the posterior rectus sheath, placement of a synthetic mesh for IH repair [14,15]. This technique is still considered the gold standard for IH repair, providing lower recurrence and SSI rates [1]. In contrast, Chevrel’s approach of placing the mesh under the subcutaneous tissue prefascially was first described in 1979 and has also gained widespread recognition [1,16,17].

In 1990, Ramirez proposed the concept of component separation, describing the anterior component separation technique . Despite revolutionising the field of abdominal wall surgery, the original technique did not encompass the use of a prosthetic mesh, and it was associated with high recurrence rates and wound morbidity [7]. Subsequently, the posterior component separation  technique was introduced in 2012, providing protection of the viscera from the mesh, closure of the rectus muscle defect, and adequate space for large mesh placement, lowering the complication and recurrence rates of its anterior counterpart. TAR was incorporated into the posterior component separation, particularly for large hernias with loss of domain, extending the dissection beyond the rectus sheath’s lateral margins in between the transversus abdominis and the transversalis fascia and further minimising the recurrence rate, while also omitting the morbidity deriving from the anterior component separation [8].

The advent of minimally invasive surgical techniques marked a fundamental shift in hernia repair, offering shorter hospitalisation and recovery time, along with reduced pain and wound morbidity [12]. LeBlanc and Booth were the first to describe a laparoscopic ventral hernia repair and demonstrate its feasibility and safety in 1993 with intraperitoneal mesh placement, which later came to be known as IPOM [18].

Subsequently, several alterations emerged by laparoscopically reproducing the principles of the open variants of Rives-Stoppa and TAR. Endoscopic methods were also implemented to address the intraperitoneal mesh-related complications, with total extraperitoneal (TEP) and its enhanced view counterpart (e-TEP) [12,19,20]. Concerning IH, Belyansky was the first to combine the principles of laparoscopic and endoscopic hernia repair with those of the TAR technique in 2016 and 2018 demonstrating their promising advantages [21,22]. However, despite the efficacy of laparoscopy, TAR is characterised by a heightened level of technical complexity due to constrained workspace and limited maneuverability of instruments, even for experienced surgeons. This is indicated by the fact that TAR is the sole procedure that transitioned directly from the open approach to the implementation of robotic surgery [21,23].

The advent of robotic systems revolutionised surgery, including hernia repair, following the approval by the Food and Drug Administration (FDA) in 2000 for use. Twenty-five years later, numerous advancements have been accomplished, and the fourth generation of robotic systems has been introduced. The advantages of robotic surgery include three-dimensional field vision, reduced hand tremor, instruments that simulate wrist movements, a more comfortable and ergonomic position during surgery, a steeper learning curve, and the reduction of pain, blood loss, and recovery time for the patient [24,25]. Despite this, some may argue that the technological advantages demonstrated do not necessarily reflect better clinical outcomes, when comparing laparoscopic to robotic surgery [25]. Yet, given the challenging nature of laparoscopic TAR, only limited case-series have been documented in the literature with encouraging outcomes, rendering it unable to address this question due to the lack of comparative studies with the open and robotic approach [21,26].

COMPARATIVE ANALYSIS OF OPEN AND ROBOTIC TAR FOR VENTRAL AND INCISIONAL HERNIAS

TAR constitutes an established and widely approved operation for ventral hernias, especially complex IH, that displays superior outcomes compared to anterior component separation and intraperitoneal techniques in terms of decreased pain, shorter length of hospital stay, and morbidity [12]. Regardless of the approach, both open and robotic techniques adhere to the same aims and principles. The restoration of the anatomy with the reinstitution of the linea alba, the preservation of the neurovascular bundles of the rectus abdominis muscle, the lack of need for large skin flaps and the almost tension-free repair of the hernia defect with sufficient mesh placement, all contribute to the applicability of TAR for complex ventral hernia repair  [5]. A total of 6 comparative studies were included in the present review, focusing on the implementation of o-TAR compared to r-TAR for ventral hernias  [27-32]. Concerning the selected studies, there was no statistically significant difference in hernia length or width among the examined groups [27-31]. The sole exception is the study by Dewulf et al., in which the o-TAR group comprised patients with a statistically substantially greater defect than the robotic group, 10.0 cm against 8.7 cm width (p=0.031) and 14.1 cm versus 11.6 cm length (p=0.005) [32]. Table 1 consolidates the postoperative outcomes for both approaches.

Operative time

All examined studies evaluated the operative time discrepancies among the two approaches [27-32]. Three retrospective studies and one case-control study discovered that r-TAR has significantly higher mean or median operational times (365, 299, 242, 272 minutes) than o-TAR (287, 211, 188, 206.5 minutes), respectively [28, 30-32]. Similarly, Abdu et al. found that 41% and 54% of hybrid r-TAR procedures lasted 180-239 and more than 240 minutes, as opposed to 26% and 39% for its open variant, respectively (p<0.001) [27]. Meanwhile, the study by Halka et al. denoted no statistically significant difference across the two approaches [29].

Intraoperative details

Another element under examination is whether the robotic approach exceeds the open technique regarding intraoperative details. Concerning fascial closure attenuation, Abdu et al. reported a significant difference among the two approaches (r-TAR 100% versus o-TAR 94%, p=0.009) [27]. Yet, in the subsequent study of Dewulf et al., the level of statistical significance was not achieved (r-TAR 98.9% versus o-TAR 93.7%, p=0.119) [31]. Abdu et al. also demonstrated evidence about the use of subcutaneous flaps, exhibiting a statistically significant advantage for r-TAR with a reported rate of 4%, compared to open with a rate of 21% (p<0.001) [27].

Furthermore, three studies examined the conversion rates of r-TAR. The conversion rate to open surgery ranges from 0 to 8.9% [27,28,31]. In particular, Bittner et al. reported no conversion rate to open attributed to the absence of intraoperative complications for the robotic approach, although the o-TAR displayed a non-significant difference in intraoperative complication rate of  5.3% (p=0.57) [25]. While Abdu et al. demonstrated a low conversion rate of 3%, Dewulf et al. experienced a three-fold greater rate (8.9%), which correlates to the occurrence of intraoperative complications involving adhesions, hemorrhage, small bowel injury, as well as gastric perforation [27,31].

Surgical site infection and surgical site occurrence

The SSI rate was recorded by all included studies, with comparable outcomes for the r-TAR and o-TAR groups [27-32]. The sole study of Dewulf et al. that managed to deliver statistically significant results, demonstrated superior outcomes for the r-TAR group (3,3% vs 12,7%, p=0,01) [31]. Although Νguyen et al. presented similar SSI rates, they did not attain statistical significance. While another study showed better SSI incidence for the o-TAR group, this was not statistically significant (6% vs 4%, p=0,44) [32].

All studies aside from one compared surgical site occurrence (SSO) rate between the two groups [27-31]. Although every study showed results favourable for r-TAR, only, Abdu et al. managed to achieve the level of statistical significance (5% vs 15%, p=0,015) [27]. In this context, Halka et al. and Bittner et al., in their retrospective studies, focused on SSOs requiring reintervention but could not end up with statistically significant results (6% vs 13,4%, p=0,2 and 3,8% vs 2,6%, p=1,0 respectively) [28,29].

Overall postoperative morbidity and mortality

One of the primary objectives of the analysed studies was the comparison of major postoperative complications between the robotic and open approach, including overall morbidity and mortality [27-31]. In particular, Martin-del-Campo et al. exhibited a statistically significant decrease (0% vs 17,1%, p=0,007) in r-TAR group for postoperative complications, including urinary tract infection (UTI), prolonged ileus (>5 days), deep venous thrombosis (DVT), pulmonary embolism and pneumonia [30]. Similar results for morbidity,employing r-TAR compared to o-TAR, were demonstrated also byDewulf et al., who took into consideration Clavien-Dindo grade 3 and greater complications ( 7,8% vs 20,3%, p=0,018) [31]. Conversely, the retrospective study of Abdu et al. reported favourable results for the o-TAR group concerning gastrointestinal tract complication-related readmissions (67% vs 23%, p=0,041). Regarding readmission, rates for wound complications were higher for the open approach, yet the results were not statistically significant (17% vs 59%, p=0,065). Although, the latter study showed no significant discrepancy for systemic complications among the two examined approaches, open outperformed r-TAR in respiratory failure rates necessitating intubation during the postoperative period (0% versus 3%, p=0.02) [27]. The studies of Halka et al. and Bittner et al. showed no discernible difference in terms of complications for r-TAR, without reaching statistical significance (p=0,32), while the latter also compared the overall morbidity among the two groups with r-TAR achieving better outcomes (19,2% vs 39,4%, p=0.09) [28,29]. The subsequent study of Nguyen et al. indicated no statistical significance for complications including UTI (p=1.0), DVT (p=0.132), pneumonia (p=0.544), and abscess (p=1.0), except for the need for ICU admission favouring r-TAR over o-TAR (3,7% vs 50% p<0.001) [32]. Evidence regarding mortality was reported in only two studies, with Martin-del-Campo et al. reporting no mortalities and Dewulf et al. reporting two deaths in each group, 2/90 (2,2%) for r-TAR and 2/79 (2,5%) for o-TAR [30,31].

Length of hospital stay 

All included studies assessed whether r-TAR results in improved outcomes in terms of length of hospital stay (LOS). As expected, r-TAR significantly outperformed the open approach in all studies, with a mean LOS ranging from 1.3 to 3.8 days compared to 5-9.6 days, respectively [27-32].

Reoperation and readmission

Another aspect worth investigating is the difference in the necessity for reoperation among the two approaches. Three out of the six studies explored this parameter [27,31,32]. Abdu et al. reported no particular significance between the r-TAR and o-TAR groups neither in terms of the reason for reoperation, which in the majority was due to major wound complication and postoperative bleeding, nor regarding the reoperation rate (4% vs 5%, p=0.89) [27]. Dewulf et al. during their long-term follow up observed a statistically non-significant difference between r-TAR and o-TAR (4.4% vs 8.9%, p=0.246), while also noted a similar hernia recurrence rate of 5.6% and 5.1%, respectively [31]. Lastly, Nguyen et al. reported that 2 of the 16 patients in the o-TAR group (12.5%) needed reoperation for wound debridement, which did not occur in the r-TAR group [32].

Regarding the necessity for readmission, five studies provided readmission rates [25,28,30-32]. Although, Abdu et al., Martin-del-Campo et al., and Dewulf et al. displayed lower readmission rates for the robotic approach, the differences didn’t reach the level of statistical significance [27,30,31]. Similarly, Nguyen et al. exhibited a 12.5% readmission rate for the open variant as opposed to 0% for the robotic group, yet the p-value was 0.132 [32]. In this context, Bittner et al. also presented comparable outcomes  (p=1.0) for the two groups with 7.7% for the r-TAR and 6.6% for the o-TAR [28].

LIMITATIONS

The present review follows a narrative methodology instead of a systematic, which may introduce selection bias by excluding pertinent studies. In addition, most included studies lacked long-term follow-up which may lead to potential underestimation of recurrence rates and long-term results. The confounding effect of the learning curve’s influence on the results of the r-TAR was not consistently considered, possibly underestimating the reported differences. In this context, the lack of comparative studies of laparoscopic TAR against the open and the robotic variants impedes the ability to draw definitive decisions regarding superiority. This review also lacks a thorough analysis of the cost variances between the open and the robotic approach, which represents an important element under consideration in daily clinical practice.

CONCLUSION

In conclusion, robotic surgery is altering the management of complex ventral hernias, including IH repair. This review highlights the historical background and the present landscape of ventral hernia repair, with a particular emphasis on the comparative analysis among o-TAR and r-TAR. Although the robotic approach necessitates longer operative times, comparable outcomes with a marked superiority of the robotic approach in some studies have been presented for surgical site infection, surgical site occurrence and overall postoperative morbidity. R-TAR displays a significant advantage over the open approach in terms of length of hospital stay, although the reoperation and readmission rates were comparable. Despite the encouraging outcomes of robotic surgery, given the limitations of the available evidence, further randomised controlled and prospective cohort studies with long-term follow-up, involving also the laparoscopic approach, are required to clarify the comparative effectiveness of robotic, open and laparoscopic techniques. Therefore, although r-TAR for ventral hernia repair represents a promising novel alternative approach, its definitive role requires additional investigation.

ACKNOWLEDGEMENTS

None.

ETHICAL STANDARDS DECLARATION

Ethical approval was not required, due to the nature of this study.

CONFLICT OF INTEREST

All authors declare no conflicts of interest.

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